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Presented by Joani Richardson, OTR/L
BehavioralSkill Development
in
Autism Spectrum Disorder
Agenda
Review Core Deficits & Associated Features of ASD
DSM 5: differences in diagnostics
Writing meaningful & measureable goals related to behavior
Data collection
Principals of teaching social and behavioral skills
Group and individual social skill development strategies
Peer involvement
Addressing Social Skills – Real Life Scenarios
Question and Answer
Autism Spectrum Disorders
3 core deficits Think of "CSI"
Communication DeficitsSocial DeficitsRestricted Interests/
Stereotyped behaviors
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Communication & Language
� Possible communication deficits
• Delay in or total tack of language
• Echolalia and/or repetitive phrases
• Odd intonation, pitch, stress, rhythm, tone, volume
• Abstract and inference based thinking
• Auditory memory, auditory processing and executive function
(organization, multi-step tasks, time management)
• Understanding figurative language: idioms, metaphors, similes, irony. They are very literal.
Social Deficits
� Impairments in the ability to initiate and sustain conversation.
� Difficulty using & understanding nonverbal behaviors.
� Failure to develop peer relationships appropriate for their age.
� Poor understanding of personal space.
� Significant difficulty taking another person’s point of view.
� Inability to maintain/use eye contact, intricately.
� Difficulty engaging in nonpreferred topic of conversation
� Difficulty transitioning between topics and activities
� Intense preoccupation / absorption in interest area.
� Strong need for “sameness”
� Problems with transitions. Seek routine.
� Strong need for closure.
� Difficulty with unstructured time and space.
� Repetitive motor movements (“flaps”, “flicks”, paces, runs, talks or hums, etc.)
Restricted Interests, Repetitive Movements,Stereotyped Behaviors.
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Four Associated Features
1. Sensory Differences
2. Cognitive Function Differences
3. Motor Differences
4. Emotional/Behavioral Differences
Sensory Differences
� Sensitivity and/or insensitivity
� May seek and/or avoid sensory input
� Difficulty with modulation (altering/fine tuning the amount)
� Difficulty with filtering (perceiving only certain information/sound)
� Difficulty with regulation of activity level
� Can vary from day to day, and time of day
� Very literal.
� Difficulty determining relevant from irrelevant.
� Skills may come and go.
� Good visual skills
� Don’t cope well with interruptions.
� Weakness in reading comprehension, problem solving, generalizations, intuitive thinking, inferences & math word problems.
Cognitive Function Differences
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� May walk with awkward gait or on toes
� Difficulty modulating force
� Tire easily
� Difficulty starting actions, even though they may have done them many times before
� Poor motor coordination and handwriting
Motor Differences
Emotional / Behavioral differences
� Rage reactions, easily stressed, aggression
� Difficulty identifying and managing stress level
� Appear non-compliant
� Limited understanding of own & others emotions
� Laugh inappropriately or at inappropriate time
� Difficulty tolerating own or others mistakes
� Anxiety
� Ritualistic and compulsive
� Impulsive
Autism Diagnosis: DSM-5
� The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released new criteria in May 2013
� Autism, Aspergers and PDD-NOS collapsed into a single diagnosis: Autism Spectrum Disorder
� ASD is a neurobiological disorder of development.
� Symptoms must be present in early childhood, but may not become fully manifest until social demands exceed limited capacities
� Symptoms together limit and impair everyday functioning.
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Changes in ASD in DSM-5
� 3 core deficits(domains) become 2� Social Communication
� Restricted Interests / Repetitive Behaviors
� Inclusion of Specifiers, such as: � "Associated with known medical or genetic condition or environmental factor” (e.g., Fragile X, VCFS, (Velo-Cardio-Facial syndrome), intrauterine valproate exposure)
� Verbal abilities
� Cognitive abilities
� Severity of symptoms in the two domains
Deficits in Social CommunicationMust have deficits in all 3:
1. Social-emotional reciprocity
2. Nonverbal communicative behaviors used for social interaction
3. Developing and maintaining relationships
Restricted, repetitive patterns of behavior, interests, or activities: Must have at least 2
1. Stereotyped or repetitive speech, motor movements, or use of objects
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment
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Why focus on social and behavioral?
We must always be working to prepare the kids
to reach their academic potential, to live independently,
AND to be gainfully employed.
They need:
Adequate Academic Skills
Independent Living Skills
"Appropriate"/Acceptable Social Behavior
Everything we do:
it's
ALL
behavior
Determine and Prioritize skill deficits
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Must have Accurate Present Level of Performance
� Parent Interview &/or checklist
� Teacher(s) Interview
� Student Interview
� Rating Scales
� Naturalistic Observation
� Structured Observation
� Social Skills Checklists
Skillstreaming (early childhood, elementary, adolescent) by Ellen McGinnis & Arnold Goldstein
"Just the facts, Ma'am"
Learn to be objective
Observe same age neurotypicals in a natural setting and write down exactly what you see in very brief time periods (‹ 3 minutes) on 3-4 different occasions.
By different people?
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For every problem situation or skill deficit, there is a replacement skill that must be taught
Write a Goal
What do you want the student to do?
� State what they should do, not what they should not. (dead mans’ test)
� Be specific and objective about what you want to see &/or hear
� Avoid vague, subjective terms such as polite, helpful, respectful, appropriate, attitude, etc.
� Make sure it’s developmentally and peer appropriate.
� Goals should be written with enough clarity that a stranger would be able to identify the presence or absence of the behavior.
� Make it measurable within the designated setting:
Who will see it and how will it be measured?
Avoid “will improve” and percentages unless in specified time frame
Data Collection
Build it into your goal
How often?
By whom?
In what context?
How is it recorded?
How do we remember to get it done?
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Example One - Problem
Background: Ben is a 6th grade student. He has an adequate verbal vocabulary to express his wants and needs clearly. He tends to speak in phrases of 4-5 words. He seeks opportunities for peer interaction during class. His voice tends to be high volume and generally monotone. He is of average intelligence.
Problem : In the classroom environment, Ben verbally announces his need in a loud voice and then immediately follows through with whatever he finds necessary. i.e.: Ben stands and shouts "bathroom" and then promptly leaves the room, or loudly states "my pencil broke" and then goes to the pencil sharpener. Situations arise approximately one time of every two class periods throughout the day in his core academic classes.
Example One - Goal
Goal: Ben will appropriately ask permission as defined on data collection sheet, to complete non-routine activities such as using the bathroom, sharpening his pencil, filling his water bottle, etc, with visual supports only, if needed (no staff prompts) in 90% of situations in one random week of data collection per 9 weeks.
Data collection sheet: Goal: Appropriately asking permission for non-routine tasks Ben raises his hand and waits quietly to be called on if teacher is instructing class, is with another student, or if class is participating in discussion. Ben quietly approaches the teacher if independent or small group work is being completed. In each situation he then asks the teacher if he may complete the necessary task and waits for a response from the teacher. He then completes the task. Note: teacher grants permission for him to complete the task when he asks.
Example Two - Problem
Background: Brittany is a 7th grade student with a very high IQ and an advanced verbal vocabulary. She has limited to no interaction with peers and adults during the school day. She independently follows all routines and does not stand out as having overt problem behaviors that interfere with classroom instruction. She responds well to visual information. Academically she is on the A honor roll.
Problem: Brittany does not indicate in anyway that she needs help or instruction. She is noted to remain quietly sitting in her seat or standing in the current location. She tends to lower her chin slightly, but remains in an upright position. Her hands tend to be idle or she fidgets with an item on her desk or in her hand. When approached and asked if she needs help by staff she says either "no", "I don't know" or remains silent.
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Example Two - Goal
Goal: In a familiar environment, with contrived situation if necessary, when approached by familiar staff and asked in a direct manner if she needs help, Brittany will verbally respond, with use of a visual script if necessary, indicating what she needs help with, in 4 of 5 situations over no greater than a 5 day period. To be monitored 2 random weeks each 9 week period.
Data Collection sheet: On the back of each scripted index card. Four columns are labeled to record:"date/time""Y/ N" for "yes"/ "no" indicating whether or not she completed the task as noted above."task" 1-3 word description of task which required help. i.e. "math worksheet", "broken pencil lead", "misplaced item" "Initials" staff member initials
Example Three - Problem
Background: Alex is an 8th grade student. He gets average grades. He has a generally age appropriate vocabulary. He has relative strengths in the areas of math and science. He is good natured, and is not disruptive. He independently follows his school schedule. He appears to enjoy peer interaction and frequently sits with peers at lunch.
Problem: When working in small groups of 3-5 students, Alex appears attentive, looking from person to person and at the project. He smiles on occasion at generally appropriate times and completes specific tasks that he is told to do by another group member. However, he remains generally silent without asking questions nor commenting on the task at hand, or on "side" conversations. In general observation on 4 occasions when directly questioned by a peer he either remains silent (~ 25%) or accurately answers the question with a 1-2 word phrase (~75%). On occasion he directs his attention to the person next to him and tells a joke which he finds funny, but that is unrelated to the topic or task.
Example Three - Goal
Goal: When working in a small group (3-5 students) on projects in his science class, using a visual cue card, Alex will respond on topic, using one of three conversational types of response, after being directly engaged by another student, in 5 of 5 opportunities over a 2 week period.
Response types: 1.) responds to statement with a statement2.) answers open ended question with at least 6 word sentence3.)responds to a statement with a question
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Your Turn: Handling Frustration
Daniel is an 8th grade student. He has adequate verbal language to
talk to peers, interact with teaching staff and get through his school day. When he gets angry or frustrated he stands up abruptly and then raises his voice and yells at the person or object of his anger. Approximately 8 out of 10 times in this situation he throws a book either down at the floor or across the room. On occasion he throws a pencil or other small object. He uses foul language toward the teaching staff if they address him. If he's asked to leave the room and he is not touched by anyone, he will follow a teacher or lead a teacher out of the room and into the hallway. Once outside the room it takes him approximately 5-10 minutes to get his anger under control before re-entering the room. He has never physically hit anyone, though the objects he throws have come quite close.
Write a Goal
� Work with a partner if you wish� Quickly pick a behavior noted in the problem that you want to
address. Don't over analyze the situation.� Don't worry about the intervention process. � Write a measurable goal.� Focus on describing the behavior you want to see.� Make sure it meets these criteria:
1. realistic goal – keep in mind, it may be a step in a progression, not the end goal
2. dead man's test3. random observer
Behavioral Skill Intervention
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Social and behavioral skills are taught using exactly the same principals we use to teach
anything else.
But they MUST be
directly taught
1. Break tasks down into small parts or steps
� If necessary, ask for help (OTs took numerous courses in
school on task analysis)
� Use reference material
� Books
� Social Skills Curriculums
� Autism related websites
BooksHundreds are available. A few I've found helpful are:
� Skillstreaming in Early Childhood (non AU specific) List of skills
Also for Elementary School Child and Adolescent
All by Ellen McGinnis & Arnold Goldstein
� A 5 Is Against the Law
By Kari Dunn Buron
� Unwritten Rules of Social Relationships
By Temple Grandin and Sean Barron
� Practical Social Skills for Autism Spectrum Disorders - Designing Child-Specific Interventions
By Kathleen Koenig
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Social Skills Curriculums
� Navigating the Social World
by Jeanette McAfee, MD
� Think Social and/or
� Thinking About You Thinking About Me, 2ndEd.
By Michelle Garcia Winner
� Building Social Relationships
By Scott Bellini Ph.D.
� Preparing for Lifeby Jed Baker
"Basic conversational manners" 10,800,000 results
"Teaching conversational skills to children with Autism"
37,500 results
Autism Related Websites
� http://www.theautismprogram.org/autism-resources/sixty-in-sixty/
� http://www.autism.org.uk/
� http://www.autismspeaks.org/family-services/tool-kits (Has an ASD Video Glossary
� http://www.autism.com (Autism Research Institute)
� http://www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf
(National Standards Project) (Page 32)
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2. Present manageable amount to ensure success
Will vary from student to student and task to task
For Example: Basic Conversational Responses
Answer yes/no questions
Start with "obvious" answers that you know to be accurate:
Did your mom drive you to school today?
Move to non-obvious things you know to be true
Do you like dinosaurs?
Move to more subjective questions
Are you hungry?
3. Build on skills they've already acquired
Basic Conversational Responses
Answer yes/no questions
Answer simple questions with a one-two word reply
Respond to a statement with a statement
Answer open-ended questions
Respond to a statement with a question
Respond to a question with a brief statement and a reciprocal question
Respond to a statement with a statement followed by a question
4. Determine if best taught in group or individual (or both)
� Advantages of Individual
� Allows you to more accurately assess student skill level
� Easier to plan when you're in unfamiliar territory
� Only one learning style to accommodate
� More room for "change of plans"
� Easier to schedule(?)
� Advantages of Group
� More realistic
� Serve more students at one time
� Different options for intervention strategies
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5. Select teaching methods
� Social Stories™
� Comic Strip Conversations
� Power Cards
� Written information
� Contrived situations with peers
� Power Point
� Role-Play
� Mirror practice
� Pictures
� Videos of others: u-tube, movies, sit-coms, peers, etc
� Videotape student
Social Stories™
� Developed by Carol Gray.
"The goal of a Social Story™ is to share relevant information… includes where and when a situation takes place, who is involved, what is occurring, and why."
� They can also:Provide missing information about the perspectives of others.Provide missing information about relevant social cues.
For Information on Social Stories™
Revealing the Hidden Social Code Social Stories™ for People with Autistic Spectrum Disorders
by Marie Howley and Eileen Arnold
The New Social Story™ Book by Carol Grey
A Treasure Chest of Behavioral Strategies for Individuals with Autism
by Beth Fouse and Maria Wheeler
www.thegreycenter.org/social-stories
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Tool used to visually illustrate the actions, feelings, thoughts and/or intentions of the various people involved in a "conflict", and to help students think of or
understand, possible solutions.
•Artistic ability is not required. Use stick figures to represent the people involved. If student draws, may choose to draw more elaborately.•Word bubbles show the words and/or thoughts of the participants from the
drawer's perspective• May also write words or thoughts in different colors to represent different
emotions• Student takes the lead in creating when possible, with adult assisting•A series of "frames" can/should be used to show the sequence of events
Sequence of events that have already occurredSequence of events that are likely to occurSequence of events with different solutions
Comic Strip ConversationsAlso by Carol Grey
• Used as a reminder or for generalization, so no training is required
• Incorporates the student’s (intense) special interest onto a single sheet or card that tells how this “hero” handles a particular situation that is currently of focus for this student.
• A short social story is also included to describe the situation more fully than can be put on the card.
• The student first reads the social story, then carries the card with him so that he can refer to the steps that his “hero” follows when he is in this situation.
Power Cards / Hero StoriesDeveloped by Elisa Gagnon
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Power Card Example
Power Card
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Written information
Prompts: wipe erase, cue cards, sticky notes, notebook page
Handouts
Scripts: role play, structured scenario, on desk, in practice, etc.
ChartsOther: graphs, graphic organizers, etc.
Contrived situations with peers
� Be thoughtful in peer selection
� Must coach/teach peers
� Small and very structured for early skill development
� May be in "therapeutic" setting first
� May need scripts for all or some
� May be improvised within guidelines or with structure
Power Point
� Make your own
� Assist the student in making one
� Use other peoples' : www.slideshare.net
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Role Play
Role-playing: two or more people act out roles in a particular scenario.
� To help prepare for unfamiliar or difficult situations and/or rehearse for an upcoming situation.
� To demonstrate problems or situations from different perspectives.
Steps
Identify the situation.
Add details.
Assign roles.
Act out the scenario, with or without scripts
Discuss what you have learned.
Mirror practice
� Great for teaching, practicing and critiquing:
� Non-verbal communication
� Pairing of verbal and non-verbal communication
� Without a model
� With a model
� Imitate an adult
� Imitate a peer
� Imitate a picture
� Imitate a video on pause or short clip
Pictures
� Books, magazines, internet, photographs
� Use pictures intended for audience below student's language and age level for initial introductions to concepts, etc.
� Student searches for picture to illustrate an emotion
� Adult gives pictures and student identifies the emotion
� Used paired with other written information (prompts, handouts, scripts, etc.) as visual reminder/cue
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Videos of others:
Make your own
Use sit-coms, movies, u-tube, etc
Videotape student
Video self modeling or "video feedforward"
� Used to facilitate skill development or language development
� Film clips are taken and then edited to show them doing a skill slightly beyond their ability level
� Labeled at the beginning and end
� With or without sound
� Student watches
6. Make a lesson plan
� Plan 3-4 sessions in advance
� Be specific, but without lots of invested time
� Pick 2-3 teaching methods per session (may not use all)
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7. Determine location/time/frequency
Location
Attend to sensory issues
What's available?
What materials, resources, equipment is necessary?
How much room for movement is needed?
Time
Is a specific environment necessary (i.e. cafeteria, quiet space, hallway, etc)?
30 minutes probably maximum per session in school setting
How much time is required for the intervention strategy?
Frequency and duration
1-2 times per week if individual
1-3 times per week if group
Rate of skill development varies significantly; 2-3 sessions verses 2-3 months
8. Peer involvement is critical
� Understanding Friends
� Catherine Faherty – Asheville TEACCH Center
� http://teacch.com/educational-approaches/ understanding-friends
� Included in specific teaching methods
� Peer Buddies
� Lunch Buddies
� Life Skills Group
� Interest Groups!
Don't forget the rest of the team
� The person with Autism is not the only person you will be teaching.
� Teachers, parents and other staff must be taught what their expected behavior is too, or skill development will not work.
Teach student
Teach rest of team
Practice
Generalize
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Review:Addressing Social & Behavioral Skills
1. Write a meaningful and measurable goal based on accurate PLP
2. Break tasks down into small parts or steps
3. Present manageable amount to ensure success
4. Build on skills they've already acquired
5. Determine if best taught in group or individual
6. Select specific teaching method(s)
7. Make a lesson plan
8. Determine location/time/frequency
9. Involve peers
10. Teach rest of team
Questions?
Presented by Joani Richardson, OTR/LProviding consultation, trainings and seminars
